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Home My WebLink AboutHandy House, Inc. - 12/31/2008COMMONWEALTH of MASSACHUSETTS TOWN of MANSFIELD BOARD of HEALTH, SIX PARK ROW SEPTAGE PUMPING AND TRANSPORTING PERMIT This is to certify that: Mark Pirnie, Operations Manager Doing business as: Handy House, Inc. P.O Box 9131 Foxboro, MA 02035 is hereby granted a SEPTAGE PUMPING AND TRANSPORTING PERMIT to engage in the pumping or transporting of the contents of privies, cesspools, septic tanks and other offensive substances. This permit is granted in conformity with the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and MGL chapter 111 section 31A and expires December31, 2008 unless sooner suspended or revoked. LIC: 22 Truck Registration Number(s): MA L38112 BOARD OF HEALTH Dr. Raymond Martin, Chairman TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD SEPTAGE PUMPERS APPLICATION Business Name: Handy House, Inc. Mail Address: P.O Box 9131 Town: Foxboro State: MA Zip Code: 02035 Name of Owner: Mark-Pirn -, Operations Manager Bus Phone: 8004421286 Fax: 508-543-4573 Fed ID/SS No.: 042563022 Date: 2007 No. of Trucks: 1 truck Registration Numbers: MA L38112 Fee: $50.00/Truck Signature: % Please make appropriate changes. Sign, date and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. TR UCK INSPECTIONS. December 4th & 51h, 8:00am to NOON, at the Town Hall, adjacent to South Common, Park Row, So. Main St. Please be there or call (508) 261-7366 if you cannot make these dates. Thank you. FOR HEALTH A GENT'S USE ONLY 3 t 0 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. 15.502 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents 15.505 Equipment: No person shall use equipment to remove or transport the contents of privies, cesspools, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. A. Mobile Tank Securely mounted on tank Watertight _Leak -proof cover ,. Tight discharge tanks B. Venting of Mobile Tanks ,1 Vent permits escape of gas, but not liquid C. Ho e Suction or pressure hose in good repair D. Pumps Maintained to prevent leaking of sewage A = Acceptable Inspected b NA = Not Acceptable Inspected on ® , R'.WeaIILUane's DocuinentsNERMIT APPLICATIONSWUMPERSAoc TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. A Signature of Individual or Corporate Name "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. R:\Hw1th\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: %"r Jy`' ;1 Address:' City/State/Zip: A 2.Phone#: Are y an employer? Check thetappropriate box: Business Type (required): 1. , I am a employer with if ' employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. lam an employer that is providing workers' compensation Insurance Company Name: a 11-4 Insurer's Address: City/State/Zip: my employees. Below is the policy information. Policy # or Self -ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the vio ator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurq ee coverage verification. I do hereby certify, un er a p'tti s and penalties ofperjury that the information provided above is true and correct. Si natureDate:' Phone #: 2 Official a e only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www,mass.gov/dia ACORD,N CERTIFICATE OF LIABILITY INSURANCE 1 DATE il/09/07 YYYY) 9/07 PRODUCER 1-212-295-8000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Integro USA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE dba Integro Insurance Brokers HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3 Times Square ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 9th Floor New York, NY 10036 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Liberty mutual Handy House, Inc. A Division of United Sites Services, Inc. INSURERB:Zurich North America New England Division INSURERC: P.O. Box 9131 Foxborough , MA 02035 INSURERD: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADD" POLICYNUMBER POLICYEFFECTIVE DD POLICYEXPIRATION DATE MMDD UMITS A GENERALLIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMSMADE nXOCCUR TB2-641-435338-027 11/03/07 11/03/08 EACHOCCURRENCE $1,000,000 D RENT AGE TO E TED PREMISES Rrence $ 100,000 MEDEXP(Anyonepemon) $10,000 PERSONAL SADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIES X POLICY PER: P'.JECT LOG PRODUCTS -COMP/OPAGG $2,000,000 A AUTOMOBILE LIABILITY ANYAUTO ALLOWNEDAUTOS SCHEDULEDAUTOS HIREDAUTOS NON -OWNED ADTD$ AS2-641-435338-037 11/03/07 11/03/08 COMBINED SINGLE LIMIT (Ea accitlenl) $2, 000, 000 X X BODILYINJURV (Per person) $ X BOOILVINnt) (Peraccidenl) $ PROPERTYDAMAGE (Peraccidant) $ GARAGE LIABILITY ANVAUTO AUTO ONLY-EAACCIDENT $ OTHERTHAN EAACC AUTOONLY: AGO $ $ B EXCESSNMBRELLA LIABILITY X1 OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ AUC 427541603 11/03/07 11/03/08 EACHOCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEWMEMBER EXCLUDED? If es,descdbeender SPECIAL PROVISIONS below WA7-64D-435338-017 11/03/07 11/03/08 X TWORVLAMRS OEH E.L. EACH ACCIDENT $1,000,000 ELDISEASE-EAEMPLOVEE $1, 000:000 E.L.DISEASE-POLICY LIMIT $1, 000000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES [EXCLUSIONS ADDED BYENDORSEMENT/SPECIAL PROVISIONS OF INSURANCE SHOULD ANY OF THE ABOVE D55CRISED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE /^ •'`—